Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northwest Manor Health Care Center during CMS and state inspections, most recent first.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Three residents with a history of falls did not have required fall prevention interventions in place, including missing or inaccessible reachers and storage pouches, lack of supervision, absence of a perimeter mattress, and nonfunctional bed alarms. Documentation of comprehensive assessments and informed consent for alarm use was also missing, and care plan interventions were not consistently followed by staff.
A resident with multiple chronic conditions was inaccurately coded on the MDS as having a fall with major injury, despite no documentation of such an event in her record. The DON confirmed only one fall without injury, and the MDS Coordinator identified the entry as an error.
A resident with total dependence and immobility was admitted without a thorough skin assessment, resulting in a large, necrotic pressure ulcer on the back of the head being missed during initial evaluations. The wound was only discovered days later when staff attempted to wash the resident's matted hair, leading to a delay in treatment.
Surveyors observed that multiple medications on two medication carts were not dated to indicate when they were opened, including eye drops and nasal spray for several residents. Some medications were also not stored according to manufacturer recommendations, such as a bottle of latanoprost that should have been refrigerated until opened. The DON acknowledged challenges in maintaining proper dating of medications, contrary to facility policy.
The facility failed to properly prepare and sanitize pureed food items, with Cook 13 not following recipes, using unmeasured ingredients, and inadequately cleaning equipment. The Dietary Manager confirmed the need for proper sanitization and consistency, which was not achieved.
The facility failed to discard expired medications and properly label a resident's supplements in two medication storage areas. An undated bottle of tuberculin serum and an unlabeled pro-stat supplement were found. The DON confirmed the labeling requirements and the need to discard the TB serum.
A resident with multiple medical conditions had inconsistent documentation of a pressure ulcer on her sacrum, with varying stages recorded in different assessments and reports. The facility's policy lacked guidance on reverse staging, and the DON indicated that MDS did not downstage pressure ulcers according to current assessments.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions as outlined in the care plans for three residents with a history of falls. One resident, with repeated falls and fractures, was observed multiple times without a reacher or accessible storage pouch, despite care plan interventions requiring these items to prevent her from leaning forward and falling. She was also left unattended in the dining room, contrary to her care plan, and her wheelchair and bed alarms were installed without documented comprehensive fall risk assessment, education, or informed consent. Another resident, diagnosed with dementia and psychosis, was found to have a regular mattress on his bed instead of the perimeter mattress with bolsters that was ordered as a fall intervention after a previous fall. Observations confirmed the absence of the required mattress, despite its inclusion in the care plan following an interdisciplinary team review. A third resident, with diabetes, weakness, and repeated falls, was found with her call light on the floor and her bed alarm pad unplugged, rendering the alarm nonfunctional. The care plan required the use of a bed alarm and education on call light use, but these interventions were not in place at the time of observation. Facility policies required comprehensive assessment, consideration of alternatives, and informed consent for alarm use, but documentation of these steps was lacking.
Inaccurate MDS Coding of Resident Fall Status
Penalty
Summary
The facility failed to accurately code a resident's fall status on the Minimum Data Set (MDS) assessment. A resident with multiple diagnoses, including chronic kidney disease, heart failure, high cholesterol, hypertension, and overactive bladder, was documented in her most recent MDS quarterly assessment as having experienced a fall with major injury. However, a review of her medical record did not contain any documentation of such a fall. The DON confirmed that the resident had only one fall, which did not result in injury, and the MDS Coordinator acknowledged that the entry was likely an error. The facility's policy addressed how to correct MDS errors but did not prevent the initial inaccurate coding.
Failure to Identify Pressure Ulcer on Admission
Penalty
Summary
The facility failed to conduct a thorough skin assessment upon admission for a resident who was admitted with a history of stroke, resulting in full body hemiparesis/hemiplegia and total dependence for all activities of daily living. Initial admission assessments documented that the resident did not have any pressure ulcers, but did note excoriation, bruises, and a laceration. The resident was bedbound and required tube feeding. Several days after admission, staff discovered a large, necrotic wound on the back of the resident's head while attempting to wash her hair, which had been matted. The wound was subsequently identified as an unstageable pressure ulcer and later reclassified as a stage IV pressure ulcer after debridement. The wound was not documented or identified during the initial admission assessments, despite the resident's immobility and high risk for pressure injuries. The wound was only discovered after a delayed inspection, and there was no evidence in the hospital records that the wound was present prior to admission. The facility's policy required a comprehensive head-to-toe skin assessment within 24 hours of admission, but the wound was missed during this process, resulting in a delay in implementing appropriate pressure ulcer treatment.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled and stored according to accepted professional principles. During observation of two medication carts on the 100 hall, several medications were found without dates indicating when they were opened. Specifically, one resident had a bottle of latanoprost that should have been refrigerated until opened and a bottle of ofloxacin eye drops with no opening date. Another resident had a bottle of fluticasone nasal spray without an opening date, and a third resident had a bottle of Systane balance also lacking an opening date. The Director of Nursing acknowledged the difficulty in keeping up with the dating of medications. The facility's policy requires medications to be stored under proper temperature controls and in accordance with state and federal laws, but these requirements were not met in the observed instances.
Improper Preparation and Sanitization of Pureed Food
Penalty
Summary
The facility failed to ensure puree food items were properly prepared and mixed according to the recipe and that the equipment was thoroughly washed and sanitized. Cook 13 was observed preparing pureed lunch without conducting hand hygiene, using unmeasured quantities of water, and not following the recipe, resulting in a thin and watery mixture. Additionally, Cook 13 did not properly wash and sanitize the blender, using only tap water and detergent with his bare, unwashed hands, and then placing the wet blender back onto the base without proper drying or sanitization. The Dietary Manager confirmed that all dishes, utensils, and equipment should be run through the dishwashing machine to ensure proper cleaning and sanitization, and that pureed foods should have a consistency similar to applesauce or pudding, which was not achieved in this case. Further observations revealed that Cook 13 continued to fail in following the recipes for pureed foods, adding unmeasured quantities of bread, gravy, and thickener to achieve the desired texture. The Dietary Manager provided the recipes, which detailed specific instructions and measurements that were not followed. The Executive Director provided a copy of the facility policy, which stated that pureed food should contain the same nutrient value as a regular diet, be seasoned appropriately, and served at the correct temperature and texture. The policy also emphasized the importance of following the recipe book for preparation and serving size, which was not adhered to during the observations.
Failure to Discard Expired Medications and Label Supplements
Penalty
Summary
The facility failed to ensure expired medications were discarded and a resident's supplements were labeled correctly in two medication storage areas. During an observation, a bottle of tuberculin serum in the Wing 1 medication room refrigerator was found undated and was a multidose vial. Additionally, a bottle of pro-stat supplement belonging to a resident in the Wing 2 medication cart was not labeled with the required minimum information. The Director of Nursing confirmed that all medications should be properly labeled and that the TB serum should have been discarded. The facility's policy on medication storage, dated 9/18, was provided, indicating that drugs in the manufacturer's original container should carry the manufacturer's expiration date and specific conditions for multi-dose vials and other medications.
Inconsistent Staging of Pressure Ulcer
Penalty
Summary
The facility failed to accurately stage a pressure ulcer for a resident with multiple medical conditions, including anemia, hypertension, hyperlipidemia, type 2 diabetes, hypothyroidism, history of stroke, difficulty speaking, and depression. The resident's pressure ulcer on her sacrum was inconsistently documented across various assessments and reports. Initially, the ulcer was referred to as unstageable, then as stage IV, stage III, and even stage II at different times. This inconsistency in staging was observed in the resident's care plan, wound assessment reports, and Minimum Data Set (MDS) assessments over several months. During an interview, the Director of Nursing (DON) indicated that the MDS did not downstage pressure ulcers for the purpose of the MDS, but rather according to the current assessment of pressure ulcers. The facility's policy on Pressure Ulcer Prevention and Managing Skin Integrity lacked documentation on reverse staging or back staging. The NPUAP Position Statement and CMS RAI manual both indicate that pressure ulcers do not heal in reverse sequence and that reverse staging is not supported as it does not accurately characterize the healing process. This discrepancy in staging led to the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eagle Valley Meadows | 1.6 mi | — | 2 | 0 |
| Evergreen Crossing And The Lofts | 2.8 mi | — | 22 | 0 |
| Westside Retirement Village | 3.3 mi | — | 31 | 0 |
| Envive Of Indianapolis | 3.4 mi | — | 15 | 0 |
| Westpark A Waters Community | 3.7 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.